Genital Herpes in
Pregnancy
By Nicette Jukelevics.
Genital herpes is a contagious,
manageable, but incurable viral infection. Thirty million
Americans are currently affected. According to the National
Institutes of Health (NIH) an estimated one-fourth of
pregnant women have been affected by genital herpes. Women
who develop a first episode of genital herpes during
pregnancy are at higher risk for miscarriage, premature
rapture of the membranes and premature delivery.
Genital herpes is caused by the
herpes simplex virus (HSV). Two types of HSV are recognized,
both of which can cause genital herpes symptoms. Type I
(HSV-1) oral herpes commonly causes cold sores or fever
blisters. Type 2 (HSV-2) is the kind that most often causes
genital sores.
The CDC estimates that between
200,000 and 500,000 Americans experience a primary episode
of genital herpes each year. Most genital herpes infections
are acquired directly by sexual contact with a partner who
has active sores in the genital area. A person with oral
herpes can transmit the infection to the genital area of a
partner during oral-genital sex. HSV can be transmitted by
someone who is asymptomatic and may not be aware of the
infection. The majority of people who become infected with
HSV never develop any symptoms. When symptoms do occur, they
vary widely. After exposure to the virus, symptoms begin to
appear within two to 20 days, and can last for
weeks.
Recurrent Outbreaks of
HSV
After the initial outbreak, the
virus can remain inactive inside nerve cells at the end of
the spinal cord and reactivate from time to time. Many
people infected with genital herpes have about five to eight
outbreaks a year. However, not everyone has recurrent
symptoms. The number of outbreaks will decrease over time,
and when they do occur, fewer sores are present. They tend
to heal faster and be less painful. Although recurrent
outbreaks cannot be predicted, they tend to occur when the
body's immune system is taxed by illness or fatigue, during
menstruation, or by sexual intercourse.
Neonatal Herpes
Although 20-25% of pregnant women
have genital herpes, less than 0.1% of newborns become
infected. Although neonatal herpes is rare, newborns who
become infected are at risk for major complications and
damage to the central nervous system. HSV can cause eye,
mouth or throat infections. The CDC estimates that 75% to
90% of newborns with HSV suffer severe long term
complications. Without treatment up to 65% of infected
newborns die.
The majority of newborns become
infected by exposure to the virus present in the birth
canal. Occasionally the virus is transmitted in utero. Less
common is the possibility of the baby becoming infected from
lesions on the mother's nipple during breast feeding or from
a father with a cold sore.
Women who were infected with the
virus before they became pregnant and do not have a
recurrent episode during pregnancy have a very small chance
of transmitting it to their babies. They have developed
antibodies that are passed on to the fetus through the
placenta.
According to the National Institute
of Allergy and Infectious Diseases (NIAID) with a first
outbreak of genital herpes that develops near the time of
delivery the baby's risk of infection is one in three. With
a recurrent outbreak the risk is less than one in
30.
Reducing the Risk of Neonatal
Herpes
Testing an expectant mother for HSV
antibodies can alert her care provider that she may be at
risk for a recurrence during her pregnancy. However, the CDC
cautions that a positive test result in an asymptomatic
pregnant woman is not a valuable predictor of the risk of
transmission, and states "in the absence of lesions during
the third trimester, routine serial cultures for herpes
simplex virus (HSV) are not indicated for women who have a
history of recurrent genital herpes. However, obtaining
cultures from such women at the time of delivery may be
useful in guiding neonatal management." (NfMWR
1998;47(No.R_R-1)
When pregnant women have active HSV
lesions, the use of anti-viral drugs is currently
recommended as the best alternative for lowering the risk of
neonatal herpes. Treating the expectant mother with
anti-viral drugs decreases the frequency of lesion outbreaks
and may decrease the risk of neonatal exposure. Three drugs
approved by the Food and Drug Administration are acyclovir
(Zovirax or Avirax), famciclovir (Famvir), and valacyclovir
(Valtrex).
According to the CDC's current
Guidelines for Treatment of Sexuaffy Transmitted Disease
(1998) "prophylactic cesarean section is not indicated for
women who do not have active genital lesions at the time of
delivery." When no lesions are observed, the American Social
Health Association recommends avoiding the use of amniotomy,
fetal scalp electrodes, and vacuum extractors or forceps to
reduce the risk of neonatal infection.
Many physicians still recommend a
cesarean birth for a woman with a history of genital herpes
despite the fact that she may not have any clinical symptoms
at the time of delivery. This approach is based on the
understanding that women may be asymptomatic but still shed
the virus at the time of delivery. However, researchers at
the University of San Francisco suggest that prophylactic
use of acyclovir in the third trimester for women with
recurrent genital herpes may lower the risk of HSV
transmission to their infants and reduce unnecessary
cesareans (Randolph et al, 1996).
The safety of systemic acyclovir
and valacyclovir therapy in pregnant women has not been
established. The CDC maintains a registry to assess their
use and effects. Although the numbers reported have not
reached statistical significance, there have been no
indications of adverse affects of anti-viral therapy during
pregnancy to date. Acyclovir is used to treat newborns
infected with HSV.
Emotional Aspects of Genital
Herpes
Although the physical aspects of an
active episode of genital herpes can be successfully
treated, its emotional impact on a pregnant woman is more
complex. Women's reactions vary and may include feelings of
anxiety, grief, and a negative self-image. Women may feel
isolated, lonely, or angry. They may feel guilty for the
possibility of transmitting the virus to their infants.
Fears about future fertility are also common.
Women who acquired genital herpes
before becoming pregnant may worry about the risk of an
active recurrence and the possibility of a cesarean birth.
Some women may need to be referred for supportive therapy
(Wooley 1997).
Although genital herpes is very
rarely a serious health problem, it can have a serious
physical and emotional impact on a pregnant woman and her
partner. Neonatal herpes may be rare, but it can be
devastating for the family. Acknowledging that genital
herpes does affect about 25% of pregnant women and referring
the parents to the wide range of educational and support
resources available in the community will enhance their
emotional well being and help them to best prepare for the
birth of their child.
*Nicette Jukelevics, MA, XCE, a
DONA-trained doula, has been teaching expectant parents for
twenty years She is a published author and speaker on VBAC
and cesarean issues. Nicette co-authored with Ruth Ancheta
The VBAC Source Book and Teaching Kit, soon to be published
by ICEA.
A longer version of this article appeared in Childbirth
Instructor, Jan/Feb 1999.
References:
- American Social Health
Association. Herpes Simplex and Pregnancy.
1997.
- National Institute of Allergy
and Infections Diseases. Genital Herpes Fact Sheet. 1997.
Retrieved online from
www.niaid.nih.gov/factsheets/stdherp.htm.
- National Institutes of Health,
Center for Disease Control and Prevention. Guidelines for
Treatment of Sexually Transmitted Diseases 1998. MMWR
1998, 47(no. RR- 1).
- Randolph AG et al. Acyclovir
prophylaxis in late pregnancy to prevent neonatal herpes:
a cost-effectiveness analysis. Obstet Gynecol 1996. 88(4
Pt 1):603-6 10.
- Wooley, Paul. Genital Herpes:
Treatment Guidelines. 1997. Published online by Medscape
Women's Health 2(5):1-10.
Resources
Education and Prevention
American Foundation for the
Prevention of
Venereal Disease,
Inc.
700 Broadway, Suite 638
New York, NY 10003
(212) 759-2069
Herpes Resource
Center
American Social Health
Association
PO Box 13827
Research Triangle Park, NC
27709-9940
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